Inpatient Treatment for Syncope
The inpatient treatment for syncope should focus on identifying and treating the underlying cause, with hospital evaluation and treatment recommended for patients who have a serious medical condition potentially relevant to the cause of syncope identified during initial evaluation. 1
Risk Stratification and Admission Criteria
Patients requiring inpatient treatment typically fall into high-risk categories:
- Cardiac causes: Patients with suspected arrhythmias, structural heart disease, or coronary heart disease
- Abnormal ECG findings: Any rhythm other than normal sinus rhythm, conduction delays, Q waves, ST abnormalities, or prolonged QT interval
- Age ≥50 years with concerning features
- Syncope during exertion or without prodrome
- Family history of sudden cardiac death
- Evidence of acute bleeding or other serious medical conditions 1, 2
Diagnostic Evaluation During Hospitalization
Once admitted, the diagnostic workup should proceed in a structured manner:
Cardiac evaluation for patients with suspected heart disease:
- Echocardiography
- Prolonged electrocardiographic monitoring
- Electrophysiological studies if non-diagnostic 1
For patients with palpitations associated with syncope:
- ECG monitoring
- Echocardiography 1
For patients with chest pain suggestive of ischemia:
- Stress testing
- Echocardiography
- ECG monitoring 1
Basic laboratory tests only if syncope may be due to:
- Loss of circulating volume
- Metabolic causes 1
Treatment Based on Etiology
Cardiac Causes
Arrhythmic causes:
Structural cardiac causes:
- Treatment of the underlying condition (e.g., medication management)
- Consideration of surgical intervention for critical aortic stenosis 1
Orthostatic Hypotension
- Volume repletion
- Review and modification of medications that may contribute to hypotension
- Consider fludrocortisone for recurrent episodes if no contraindications exist 2
Neurally Mediated (Vasovagal) Syncope
While most patients with presumptive vasovagal syncope can be managed as outpatients 1, those admitted due to frequent recurrent episodes or injuries may benefit from:
- Patient education on triggers and premonitory symptoms
- Teaching counter-pressure maneuvers (leg crossing with muscle tensing, hand gripping, arm tensing)
- Ensuring adequate hydration (2L fluid daily) and salt intake
- Consider midodrine for recurrent episodes if no hypertension, heart failure, or urinary retention are present 2
Specialized Care Approaches
For complex or unclear cases, a multidisciplinary approach may be beneficial:
Syncope Observation Units in the ED, with appropriate resources and multidisciplinary collaboration, can improve diagnostic yield, reduce hospital admission, and achieve favorable long-term outcomes 1
Structured ED observation protocols can be effective in reducing hospital admission for intermediate-risk patients with an unclear cause of syncope 1
Discharge Planning
Before discharge, ensure:
- The cause of syncope has been identified or risk stratified
- Appropriate treatment has been initiated
- Patient education on managing their specific condition has been provided
- Follow-up arrangements are in place, potentially at a specialized syncope unit 1
Common Pitfalls to Avoid
- Premature discharge without identifying the underlying cause in high-risk patients
- Overuse of diagnostic tests in low-risk patients with clear vasovagal syncope
- Failure to review medications that may contribute to syncope
- Missing cardiac causes of syncope, which carry the highest mortality risk
- Inadequate monitoring for patients with suspected arrhythmic causes
If the diagnosis remains uncertain after initial evaluation and there is potential risk of dangerous consequences, the patient should be referred to appropriate specialists (cardiologist, internist, neurologist) or to a specialized syncope facility if available 1.